Failure to Provide Comprehensive Compliance and Ethics Training
Penalty
Summary
Facility staff failed to provide a training program or another practical method to effectively communicate the standards, policies, and procedures of the compliance and ethics program to all staff. During a review of the facility's education and training records, surveyors found only a binder containing a table of education topics, including Compliance and Ethics, with a note indicating 'Review and packet.' Attached to this document was a sign-in sheet for a skills fair, but there was no documented evidence that a structured training program was provided or that all staff, including those not present at the skills fair, received the required education on the compliance and ethics program. Interviews with facility leadership confirmed the lack of comprehensive documentation and substantiation of compliance and ethics training. The Regional Director of Operations and the Administrator both acknowledged gaps in the education process, noting that some training was provided on an as-needed basis and that a new educator had only recently started, conducting some training remotely. There was no evidence to show that the standards, policies, and procedures of the compliance and ethics program were effectively communicated to the entire staff.